Healthcare Provider Details

I. General information

NPI: 1902022601
Provider Name (Legal Business Name): DETROIT USCG PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43355 NORTH JEFFERSON USCG CLINIC - BLDG 825
DETROIT MI
48045
US

IV. Provider business mailing address

2450 STANLEY RD STE 208 ATTN HECTOR MORALES
FORT SAM HOUSTON TX
78234-6102
US

V. Phone/Fax

Practice location:
  • Phone: 586-307-5017
  • Fax:
Mailing address:
  • Phone: 210-221-8443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. HECTOR MORALES
Title or Position: MANAGER DOD PHARMACY OPERATIONS CTR
Credential:
Phone: 210-221-8443